Form 3 State Licensure or Certification

State Licensure or Certification Forms and Instructions

Non-visible Questions
Label

PDF Name
(step)

Location

Response
Input Item

Visibility Trigger

Other

Date of Death

State
Below "Is this
Licensure (1) person
deceased?"

Text Entry The field is displayed
if the user selects the
"Yes" radio button for
"Is this person
deceased?"

Organization
Description

State
Below
Licensure (1) Organization
Type

Text Entry

The field is displayed
if the user selects an
organization type
that requires a
description.

Description of
Other Type of
License,
Registration,
Certification,
Permit or
Other
Authorization

State
Below the
Licensure (1) “Add a related
license…”
checkbox

Text Entry

If the checkbox is
selected the
Description of Other
Type of License is
displayed

This information is
only collected if the
action involved a
license or
certification that is
not the professional
license to practice.

State

State
Below
Licensure (1) Description of
Other Type of
License text
entry

Drop List

If the checkbox is
selected the State is
displayed

This information is
only collected if the
action involved a
license or
certification that is
not the professional
license to practice.

ID Number

State
Below
Licensure (1) Description of
Other Type of
License text
entry

Text Entry

If the checkbox is
selected the ID
Number is displayed

This information is
only collected if the
action involved a
license or
certification that is
not the professional
license to practice.

Label

PDF Name
(step)

Location

Response
Input Item

Visibility Trigger

Other

Specialty

State
Beside
Licensure (1) Profession or
Field of
Licensure

Text entry

The field is displayed
if the user selects a
profession or field of
licensure that
requires a
description.

“Specialty” is
displayed in place of
“Description” if the
profession or field of
licensure requires
specialty
information.

Description

State
Beside
Licensure (1) Profession or
Field of
Licensure

Drop List

The field is displayed
if the user selects a
profession or field of
licensure that
requires information
for specialty.

“Description is
displayed in place of
“Specialty” if the
profession or field of
licensure does not
require information
for specialty.

FEIN (Federal
Employer
Identification
Number)

State
Below
Text Entry
Licensure (1) checkbox
"Does the
subject have an
FEIN, or UPIN
identification
number?"

The field is displayed
in the individual
report form if the
user selects the
checkbox for "Does
the subject have an
FEIN, or UPIN
identification
number?"

Selecting the
checkbox displays
FEIN and UPIN text
entry fields.

UPIN (Unique
Physician
Identification
Numbers)

State
Below FEIN
Licensure (1) text entry

The field is displayed
in the individual
report form if the
user selects the
checkbox for "Does
the subject have an
FEIN, or UPIN
identification
number?"

Selecting the
checkbox displays
FEIN and UPIN text
entry fields.

Text Entry

Label

PDF Name
(step)

Location

Response
Input Item

Visibility Trigger

Text Entry

The field is displayed
in the organization
report form if the
user selects the
checkbox for "Does
the subject have a
FDA or CLIA
identification
number?"

Selecting the
checkbox displays
FDA and CLIA, and
text entry fields.

CLIA (Clinical
Laboratory
Improvement
Act)

State
Below text
Text Entry
Licensure (1) entry FDA
(Federal Food
and Drug
Administration)

The field is displayed
in the organization
report form if the
user selects the
checkbox for "Does
the subject have a
FDA or CLIA
identification
number?"

Selecting the
checkbox displays
FDA and CLIA, and
text entry fields.

Type of
Affiliation

State
Below "Is the
Drop List
Licensure (1) practitioner
affiliated with a
health care
entity?"
checkbox

The field is displayed
if the user selects the
"Is the practitioner
affiliated with a
health care entity?"
checkbox

Selecting the
checkbox displays
Type of Affiliation,
Entity Name,
Country, Address,
Address Line 2, City,
State and ZIP
entries.

Entity Name

State
Below Type of
Licensure (1) Affiliation

Text Entry The field is displayed
if the user selects the
"Is the practitioner
affiliated with a
health care entity?"
checkbox

Selecting the
checkbox displays
Type of Affiliation,
Entity Name,
Country, Address,
Address Line 2, City,
State and ZIP
entries.

FDA (Federal
State
Below
Food and Drug Licensure (1) checkbox
Administration)
"Does the
subject have a
FDA or CLIA
identification
number?"

Other

Label

PDF Name
(step)

Location

Response
Input Item

Visibility Trigger

Other

The field is displayed
if the user selects the
"Is the practitioner
affiliated with a
health care entity?"
checkbox

Selecting the
checkbox displays
Type of Affiliation,
Entity Name,
Country, Address,
Address Line 2, City,
State and ZIP
entries. United
States is the default
selection.

Country

State
Below "Is the
Drop List
Licensure (1) practitioner
affiliated with a
health care
entity?"
checkbox

Address

State
Below Country
Licensure (1)

Text Entry The field is displayed
if the user selects the
"Is the practitioner
affiliated with a
health care entity?"
checkbox

Selecting the
checkbox displays
Type of Affiliation,
Entity Name,
Country, Address,
Address Line 2, City,
State and ZIP
entries.

Address Line 2

State
Below Address
Licensure (1)

Text Entry The field is displayed
if the user selects the
"Is the practitioner
affiliated with a
health care entity?"
checkbox

Selecting the
checkbox displays
Type of Affiliation,
Entity Name,
Country, Address,
Address Line 2, City,
State and ZIP
entries.

City

State
Below Address Text Entry
Licensure (1) Line 2

The field is displayed
if the user selects the
"Is the practitioner
affiliated with a
health care entity?"
checkbox

Selecting the
checkbox displays
Type of Affiliation,
Entity Name,
Country, Address,
Address Line 2, City,
State and ZIP
entries.

Label

PDF Name
(step)

Location

Response
Input Item

Visibility Trigger

Other

State

State
Below City
Licensure (1)

Drop List

The field is displayed
if the user selects the
"Is the practitioner
affiliated with a
health care entity?"
checkbox

Selecting the
checkbox displays
Type of Affiliation,
Entity Name,
Country, Address,
Address Line 2, City,
State and ZIP
entries.

ZIP

State
Below State
Licensure (1)

Text Entry The field is displayed
if the user selects the
"Is the practitioner
affiliated with a
health care entity?"
checkbox

Selecting the
checkbox displays
Type of Affiliation,
Entity Name,
Country, Address,
Address Line 2, City,
State and ZIP
entries.

Describe the
State
type of
Licensure(1)
registration,
certification,
permit or other
authorization
affected by the
action.

Below Other
license or
certification
action

Text Entry

The field is displayed
if the user selects the
" Other license or
certification action "
option

Selecting the option
displays Describe
the type of
registration, State
and ID Number
fields.

State

State
Licensure(1)

Below Other
license or
certification
action

Drop List

The field is displayed
if the user selects the
" Other license or
certification action "
option

Selecting the option
displays Describe
the type of
registration, State
and ID Number
fields.

ID Number

State
Licensure(1)

Below Other
license or
certification
action

Text Entry

The field is displayed
if the user selects the
" Other license or
certification action "
option

Selecting the option
displays Describe
the type of
registration, State
and ID Number
fields.

Label

PDF Name
(step)

Location

Response
Input Item

Visibility Trigger

Other

Was the action State
Below Adverse Radio
taken against a Licensure (2) Action(s) Taken buttons
multi-state
license?

The fields are
displayed if the user
selects a type of
professional license
that has a multi-state
license. Options are
“Yes” and “No”

If the selected
profession does not
have a multi-state
license then this
option is not
displayed.

Select up to 5
actions

State
Below “Was
Check
Licensure (2) the action
Boxes
taken against a
multi-state
license?”

The appropriate
fields are displayed
when the user selects
a radio button for
“Was the action
taken against a multistate license?”

If the selected
profession does not
have a multi-state
license then the
fields are not
hidden.

Description

State
Below an
Licensure (2) action
requiring a
description

Text Entry

The field is displayed
if the user selects an
action that requires a
description.

Description

State
Below Basis of
Licensure (2) Action(s)

Text Entry

The field is displayed
if the user selects a
basis of action that
requires a
description.

Period of time
number

State
Below “How
Licensure (2) long will it
remain in
effect?”

Text Entry

The field is displayed
if the user selects “A
specific period of
time” option for
“How long will it
remain in effect?”

Selecting the radio
button displays the
number text entry
and type of time
period drop list.

Period of time
type

State
Below “How
Licensure (2) long will it
remain in
effect?”

Drop List

The field is displayed
if the user selects “A
specific period of
time” option for
“How long will it
remain in effect?”

Selecting the radio
button displays the
number text entry
and type of time
period drop list.

Label

PDF Name
(step)

Location

Response
Input Item

Is
State
reinstatement Licensure (2)
automatic after
this period of
time?

Below “How
long will it
remain in
effect?”

Is the adverse State
action
Licensure (2)
specified in this
report based
on the
subject’s
professional
competence or
conduct, which
adversely
affected, or
could have
adversely
affected, the
health or
welfare of
patient(s)?

Below “Is
Radio
reinstatement Buttons
automatic after
this period of
time?”

Date of Appeal State
Below Is the
Licensure (2) action on
appeal?

Radio
Buttons

Text Entry

Visibility Trigger

Other

The fields are
displayed if the user
selects “A specific
period of time” for “Is
reinstatement
automatic after this
period of time?

Available options
are “No,” “Yes” and
“Yes with conditions
(Requires a Revision
to Action report
when status
changes)

The fields are
displayed if the user
selects a license
profession of
Physician (MD),
Physician (DO) or
Dentist for the
practitioner in
Subject Information

Available options
are “Yes” and “No”

The field is displayed
if the user selects Yes
option for “Is the
action on appeal?”

State Changes
Label

PDF Name

Item Type

Trigger

OMB Number:
0915-0126
Expiration
Date:
mm/dd/yyyy

State Licensure

Modal

When the user selects the link the modal is displayed
with the public burden statement content.

Select a
Profession or
Field of
Licensure

State Licensure

Modal

When the user sets focus on the Profession or Field of
Licensure text entry, the modal to select a profession
is displayed and focus is set on the Search text
entry. The user can enter text in the Search text box
to find a specific profession or select a profession
from the list without searching. The modal is hidden
once the user selects a profession from the list. The
user's selection populates the Profession or Field of
Licensure text entry.

License
Number

State Licensure

Text Entry

Text entry is disabled if the user selects the "No/ Not
sure" option for "Does the subject have a license for
the selected profession or field of licensure?"

Select a Basis
for Action

State Licensure

Modal

When the user sets focus on the Basis for Action(s)
text entry, the modal to select an act is displayed and
focus is set on the Search text entry. The user can
enter text in the Search text box to find a
specific basis or select a basis from the list without
searching. The modal is hidden once the user selects
a basis from the list. The user's selection populates
the Basis for Action(s) text entry.